13) Chapter 44: Care of Patients with Problems of the Central Nervous System: The Brain

The client is admitted into the emergency department with frontal-temporal pain, preceded by a visual disturbance. The client is upset and thinks it is a stroke. What does the nurse suspect may be occurring? A. Stroke B. Tension headache C. Classic migraine D. Cluster headache

C. Classic migraine Rationale A. The client's symptoms do not indicate a stroke. B. The client's symptoms do not indicate a tension headache. C. The client's symptoms match those of a classic migraine. D. The client's symptoms do not indicate a cluster headache.

The nurse is reviewing the history of a client who has been prescribed topiramate (Topamax) for treatment of intractable partial seizures. The nurse plans to contact the health care provider if the client has which condition? A. Bipolar disorder B. Diabetes mellitus C. Glaucoma D. Hypothyroidism

A. Bipolar disorder Rationale A. Cases of suicide have been reported, most often in clients with bipolar disorder. B. Topiramate is not contraindicated in clients with diabetes mellitus. C. Topiramate is not contraindicated in clients with glaucoma. D. Topiramate is not contraindicated in clients with hypothyroidism.

The spouse of the client with Alzheimer's disease (AD) is listening to the hospice nurse explaining the client's drug regimen. Which statement by the spouse indicates an understanding of the nurse's instruction? A. "Donepezil (Aricept) will treat the symptoms of Alzheimer's disease." B. "Memantine (Namenda)is indicated for treatment of early symptoms of Alzheimer's disease. C. "Rivastigmine (Excelon) is used to treat depression." D. "Sertraline (Zoloft) will treat the symptoms of Alzheimer's disease."

A. "Donepezil (Aricept) will treat the symptoms of Alzheimer's disease." Rationale A. Cholinesterase inhibitors (e.g., donepezil) are approved for the symptomatic treatment of Alzheimer's disease. B. Memantine (Namenda) is indicated for advanced Alzheimer's disease. C. Rivastigmine (Excelon) is a cholinesterase inhibitor that is used to treat Alzheimer's symptoms. Selective serotonin reuptake inhibitors (SSRIs) are antidepressants and may be used in Alzheimer's clients who develop depression. D. Some clients with Alzheimer's disease experience depression and may be treated with antidepressants such as sertraline.

The nurse's friend fears that his mother is getting old, saying that she is becoming extremely forgetful and disoriented and is beginning to wander. What is the nurse's best response? A. "Have you taken her for a checkup?" B. "She has Alzheimer's disease." C. "That is a normal part of aging." D. "You should look into respite care."

A. "Have you taken her for a checkup?" Rationale A. The mother's symptoms indicate possible Alzheimer's disease or some other physiologic imbalance, and she should be assessed further by a physician. B. The nurse cannot make this diagnosis. The mother should be formally assessed by a physician. C. The mother's behavior is not normal age-related behavior. D. Respite care is for caregivers, not for clients.

The client has been diagnosed with Huntington disease. The nurse is teaching the client and her parents about the genetic aspects of the disease. Which statement made by the parents demonstrates a good understanding of the nurse's teaching? A. "If she has children, she'll pass the gene on to her kids." B. "She could only have gotten the disease from both of us." C. "Because she got the gene from her father, she'll live longer than other people with the disease." D. "More testing should definitely be done to see if she's really got the gene."

A. "If she has children, she'll pass the gene on to her kids." Rationale A. An autosomal dominant trait with high penetrance, such as Huntington disease, means that a person who inherits just one mutated allele has an almost 100% chance of developing the disease. B. Only one defective gene is needed to inherit Huntington disease. The client could have inherited it from her father or mother. C. If the client inherited the gene from her mother, she would live a longer life than other people with the disease. If she inherited the gene from her father, her life would be shorter. D. Additional testing is not necessary. If the client has Huntington disease, then the client has the gene.

The parents of a young child report that their child sometimes stares blankly into space for just a few seconds and then gets very tired. The nurse anticipates that the child will be assessed for which seizure disorder? A. Absence B. Myoclonic C. Simple partial

A. Absence Rationale A. Absence seizures are more common in children and consist of brief (often just seconds) periods of loss of consciousness and blank staring, as though he or she is daydreaming. B. Myoclonic seizures are characterized by brief jerking or stiffening of the extremities, which may occur singly or in groups. C. Partial seizures are most often seen in adults. D. Tonic seizures are characterized by an abrupt increase in muscle tone, loss of consciousness, and autonomic changes lasting from 30 seconds to several minutes.

The client newly diagnosed with Parkinson disease is being discharged. Which instruction is best for the nurse to provide to the client's spouse? A. Administer medications promptly on schedule to maintain therapeutic drug levels. B. Complete activities of daily living for the client. C. Speak loudly for better understanding. D. Provide high-calorie, high-carbohydrate foods to maintain the client's weight.

A. Administer medications promptly on schedule to maintain therapeutic drug levels. Rationale A. This is a correct statement. B. The client should be encouraged to do as much as possible on his own. C. Slow speech rather than loud speech is more effective for the client with Parkinson disease. D. Small, frequent meals are more effective for the client with Parkinson disease.

The client with a migraine is lying in a darkened room with a wet cloth on the head after receiving analgesic drugs. What will the nurse do next? A. Allow the client to remain undisturbed. B. Assess the client's vital signs. C. Remove the cloth because it can harbor microorganisms. D. Turn on the lights for a neurologic assessment.

A. Allow the client to remain undisturbed. Rationale A. At the beginning of a migraine attack, the client may be able to alleviate pain with analgesics and by lying down and darkening the room with a cool cloth on his or her forehead. If the client falls asleep, he or she should remain undisturbed until awakening. B. Assessing the client' vital signs will disturb the client unnecessarily. C. A cool cloth is helpful for the client with a migraine and does not present enough of a risk that it should be removed. D. This is not appropriate because light can cause the migraine to worsen.

The wife of the client with Alzheimer's disease mentions to the home health nurse that although she loves him, she is exhausted caring for her husband. What does the nurse suggest to alleviate caregiver stress? A. Arranges for respite care B. Provides positive reinforcement and support to the wife C. Restrains the client for a short time each day, to allow the wife to rest D. Teaches the client improved self-care

A. Arranges for respite care Rationale A. Respite care can give the wife some time to re-energize and will provide a social outlet for the client. B. Providing positive reinforcement and support is encouraging but does not help the wife's situation. C. Restraints are almost never appropriate and are used only as an absolute last resort. D. The client with Alzheimer's disease typically is unable to learn improved self-care.

The client is admitted with bacterial meningitis. Which nursing intervention is the highest priority for this client? A. Assessing neurologic status at least every 2 to 4 hours B. Decreasing environmental stimuli C. Managing pain through drug and nondrug methods D. Strict monitoring of hourly intake and output

A. Assessing neurologic status at least every 2 to 4 hours Rationale A. The most important nursing intervention for clients with meningitis is the accurate monitoring and recording of their neurologic status, vital signs, and vascular assessment. The client's neurologic status and vital signs should be assessed at least every 4 hours, or more often if clinically indicated. The priority for care is to monitor for early neurologic changes that may indicate increased intracranial pressure (ICP), such as decreased level of consciousness (LOC). B. Decreasing environmental stimuli is helpful for the client with bacterial meningitis but is not the highest priority. C. Clients with bacterial meningitis report severe headaches requiring pain management, but this is the second-highest priority. D. Assessing fluid balance while preventing overload is not the highest priority.

The client is being discharged to home with progressing stage I Alzheimer's disease. The family expresses concern to the nurse about caring for their parent. What is the priority for best continuity of care? A. Assigning a case manager B. Ensuring that all family questions are answered before discharge C. Providing a safe environment D. Referring the family to the Alzheimer's Association

A. Assigning a case manager Rationale A. Whenever possible, the client and family should be assigned a case manager who can assess their needs for health care resources and facilitate appropriate placement throughout the continuum of care. B. This is necessary for family support but is not relevant for continuity of care. C. This is necessary for safety but is not relevant for continuity of care. D. This is necessary for appropriate resource referral but is not relevant for continuity of care.

A client receiving sumatriptan (Imitrex) for migraine headaches is experiencing adverse effects after taking the drug. Which adverse effect is of greatest concern to the nurse? A. Chest tightness B. Skin flushing C. Tingling feelings D. Warm sensation

A. Chest tightness Rationale A. Triptan drugs are contraindicated in clients with coronary artery disease because they can cause arterial narrowing; the nurse should instruct the client to not take the medication until the nurse can talk with the prescribing health care provider. B. Skin flushing is a common adverse effect with triptan medications and is not an indication to avoid using this group of drugs. C. Tingling feelings is a common adverse effect with triptan medications and is not an indication to avoid using this group of drugs. D. A warm sensation is a common adverse effect with triptan medications and is not an indication to avoid using this group of drugs.

Which change in the cerebrospinal fluid (CSF) indicates to the nurse that the client may have bacterial meningitis? A. Cloudy, turbid CSF B. Decreased white blood cells C. Decreased protein D. Increased glucose

A. Cloudy, turbid CSF Rationale A. Cloudy, turbid cerebrospinal fluid is a sign of bacterial meningitis. Clear fluid is a sign of viral meningitis. B. Increased white blood cells is a sign of bacterial meningitis. C. Increased protein is a sign of bacterial meningitis. D. Decreased glucose is a sign of bacterial meningitis.

The client with Parkinson disease is being discharged home with his wife. To ensure compliance with the management plan, which discharge action is most effective? A. Involving the client and his wife in developing a plan of care B. Setting up visitations by a home health nurse C. Telling his wife what the client needs D. Writing up a detailed plan of care according to standards

A. Involving the client and his wife in developing a plan of care Rationale A. Involving the client and spouse in developing a plan of care is the best way to ensure compliance. B. Home health nurse visitations are generally helpful but may not be needed for this client. C. Instructing the spouse about the client's needs does not reinforce the spouse's involvement and buy-in with the management plan. D. Providing the spouse with a written plan of care does not reinforce the spouse's involvement and buy-in with the management plan.

The client with early-stage Alzheimer's disease is admitted to the surgical unit for a biopsy. Which client problem is the priority? A. Potential for injury related to chronic confusion and physical deficits B. Risk for reduced mobility related to progression of disability C. Potential for skin breakdown related to immobility and/or impaired nutritional status D. Lack of social contact related to personality and behavior changes

A. Potential for injury related to chronic confusion and physical deficits Rationale A. The priority for interdisciplinary care is safety. Chronic confusion and physical deficits place the client with Alzheimer's disease at high risk for injury. B. This is not a priority for a short hospital stay. This problem is usually the result of long-term care. C. This is not a priority for a short hospital stay. This problem is usually the result of long-term care. D. This is not a priority for a short hospital stay. This problem is usually the result of long-term care.

Which nursing intervention is appropriate when caring for a client with Alzheimer's disease? A. Provide a large clock and calendar. B. Place the client in a geri-chair to prevent wandering. C. Insert a urinary catheter to prevent incontinence. D. Place the client in the nurse's station.

A. Provide a large clock and calendar. Rationale A. Providing a large clock and calendar may stimulate cognition. The nurse will also be able to use these tools to orient the client to date and time. The clock and calendar should not be abstract, because this may frighten the client. The purpose of cognitive stimulation and memory training is to reinforce or promote desirable cognitive function and facilitate memory. Reference: p. 953, Safe and Effective Care Environment B. Placing the client in a geri-chair is considered a physical restraint and should be avoided. Reference: p. 953, Safe and Effective Care Environment C. The client should be placed on a toileting schedule, but an indwelling catheter is not necessary. Removing the catheter while the balloon remains inflated may increase the client's risk for injury. A foreign object such as a catheter may also increase the client's confusion and agitation. Reference: p. 953, Safe and Effective Care Environment D. The client should not be placed near the nursing station because of the level of noise and activity. In addition to disturbed sleep, other negative effects of high noise levels include decreased nutritional intake, changes in blood pressure and pulse rates, and feelings of increased stress and anxiety. The client with AD is especially susceptible to these changes and must have as much undisturbed sleep at night as possible. Fatigue increases confusion and behavioral manifestations such as agitation and aggressiveness. Reference: p. 953, Safe and Effective Care Environment

The nurse is teaching the client newly diagnosed with migraine about trigger control. Which statement made by the client demonstrates good understanding of the teaching plan? A. "I can still eat Chinese food." B. "I must not miss meals." C. "It is okay to drink a few wine coolers." D. "I need to use fake sugar in my coffee."

B. "I must not miss meals." Rationale A. Monosodium glutamate (MSG)-containing foods are a trigger for many people suffering from migraines and should be eliminated until the triggers are identified. B. Missing meals is a trigger for many people suffering from migraines. The client should not skip any meals until the triggers are identified. C. Alcohol is a trigger for many people suffering from migraines and should be eliminated until the triggers are identified. D. Artificial sweeteners are a trigger for many people suffering from migraines and should be eliminated until the triggers are identified.

The female client with newly diagnosed migraine is being discharged with a prescription for sumatriptan (Imitrex). Which comment by the client indicates an understanding of the nurse's discharge instructions? A. "Sumatriptan should be taken as a last resort." B. "I must report any chest pain right away." C. "Birth control is not needed while taking sumatriptan." D. "St. John's wort can also be taken to help my symptoms."

B. "I must report any chest pain right away." Rationale A. Sumatriptan must be taken as soon as migraine symptoms appear. B. Chest pain must be reported immediately with the use of sumatriptan. C. Remind the client to use contraception (birth control) while taking the drug because it may not be safe for women who are pregnant. D. Triptans should not be taken with selective serotonin reuptake inhibitors (SSRIs) or St. John's wort, an herb used commonly for depression.

The nurse is caring for the client with advanced Alzheimer's disease. Which communication technique is best to use with this client? A. Providing the client with several choices to choose from B. Assuming that the client is not totally confused C. Waiting for the client to express a need D. Writing down instructions for the client

B. Assuming that the client is not totally confused Rationale A. Choices should be limited. Too many choices causes frustration and increased confusion in the client. B. Never assume that the client is totally confused and cannot understand what is being communicated. C. Rather than waiting for the client to express a need, try to anticipate the client's needs and interpret nonverbal communication. D. Rather than writing down instructions, provide the client instructions with pictures, and put them in a highly visible place.

Which is the most effective way for the college student to minimize the risk for bacterial meningitis? A. Avoiding large crowds B. Getting the meningitis polysaccharide vaccine C. Taking a daily vitamin D. Taking prophylactic antibiotics

B. Getting the meningitis polysaccharide vaccine Rationale A. Avoiding large crowds is helpful but is not practical for the college student. B. People who live in highly populated areas, such as a college dorm, should get the meningitis polysaccharide vaccine (Menomune) to prevent infection. C. Taking a daily vitamin is helpful but is not the best way to safeguard against bacterial meningitis. D. Taking prophylactic antibiotics is inappropriate because it leads to antibiotic-resistant strains of microorganisms.

The nurse is caring for a client diagnosed with partial seizures after encephalitis, who is to receive carbamazepine (Tegretol). The nurse plans to monitor the client for which adverse effects? Select all that apply. A. Alopecia B. Headaches C. Dizziness D. Diplopia E. Increased blood glucose

B. Headaches C. Dizziness D. Diplopia Rationale Carbamazepine does not cause alopecia. Divalproex (Depakote) and valproic acid (Depakene) may cause alopecia.

The client has been admitted with new-onset status epilepticus. Which seizure precautions does the nurse put in place? Select all that apply. A. Bite block at the bedside B. Intravenous access C. Continuous sedation D. Suction equipment at the bedside E. Siderails up

B. Intravenous access D. Suction equipment at the bedside E. Siderails up Rationale Bite blocks or padded tongue blades should not be used because the client's jaw may clench, causing teeth to break and possibly obstructing the airway.

A client with a history of seizures is placed on seizure precautions. What emergency equipment will the nurse provide at the bedside? Select all that apply. A. Padded tongue blade B. Oxygen setup C. Nasogastric tube D. Suction setup E. Artificial oral airway

B. Oxygen setup D. Suction setup E. Artificial oral airway Rationale Clients placed on seizure precautions should have an oxygen setup, suction equipment, and an artificial oral airway at the bedside. Maintaining a patent airway is the priority for this client's care. Intubation by an anesthesia provider or respiratory therapist may be necessary. Oxygen may need to be administered as indicated by the client's condition. Padded tongue blades do not belong at the bedside and should NEVER be inserted into the client's mouth because the jaw may clench down as soon as the seizure begins. Forcing a tongue blade or airway into the mouth is more likely to chip the teeth and increase the risk of aspirating tooth fragments than prevent the client from biting the tongue. Furthermore, improper placement of a padded tongue blade can obstruct the airway. There is no physiologic reason to place a nasogastric tube emergently for a client experiencing seizure activity. In fact, convulsions may make it difficult to place the tube and put the client at risk.

The nurse has received report on a group of clients. Which client requires the nurse's attention first? A. Adult who is lethargic after a generalized tonic-clonic seizure B. Young adult who has experienced four tonic-clonic seizures within the past 30 minutes C. Middle-aged adult with absence seizures who is staring at a wall and does not respond to questions D. Older adult with a seizure disorder who has a temperature of 101.9° F (38.8° C)

B. Young adult who has experienced four tonic-clonic seizures within the past 30 minutes Rationale A. This not a medical emergency and does not require immediate attention. B. This client is experiencing status epilepticus, which is a medical emergency and requires immediate intervention. C. This is not a medical emergency and does not require immediate attention. D. A fever of 101.9° F (38.8° C) is not a medical emergency and does not require immediate attention.

The nursing instructor asks the student nurse caring for a client with Alzheimer's disease who has been prescribed donepezil (Aricept) how the drug works. Which response by the nursing student best explains the action of donepezil? A. "The reuptake of serotonin is blocked." B. "Donepezil prevents the increase in the protein beta amyloid." C. "It delays the destruction of acetylcholine by acetylcholinesterase." D. "Dopamine levels are increased."

C. "It delays the destruction of acetylcholine by acetylcholinesterase." Rationale A. Donepezil is not a serotonin reuptake inhibitor. B. Donepezil is a cholinesterase inhibitor and does not work on the protein beta amyloid. C. By delaying the destruction of acetylcholine, donepezil improves cholinergic neurotransmission in the central nervous system (CNS), thus delaying the onset of cognitive decline. D. Donepezil does not work on dopamine receptors.

The home health nurse is checking in on the client with dementia and the client's spouse. The spouse confides to the nurse, "I am so tired and worn out." What is the nurse's best response? A. "Can't you take care of your spouse?" B. "Establishing goals and a daily plan can help." C. "Make sure you take some time off and take care of yourself too." D. "That's not a very nice thing to say."

C. "Make sure you take some time off and take care of yourself too." Rationale A. This response is not supportive and may offend the spouse. B. A better response would be, "Take one day at a time." C. This response is supportive and reminds the spouse that he or she cannot care for the client when exhausted. Of course, further assessment and planning will be necessary. D. This response is judgmental and inappropriate.

A client with Alzheimer's disease asks the nurse to find her mother, who is deceased. What is the nurse's best response? A. "Your mother died over 20 years ago." B. "I'll find your mother as soon as I finish passing meds." C. "What did your mother look like?" D. "I'll ask your daughter to find your mother."

C. "What did your mother look like?" Rationale A. For the client in the later stages of AD, reality orientation does not work and often increases agitation. Reference: p. 951, Psychosocial Integrity B. Telling the client to wait until medications have been issued or that her daughter will find her mother is not consistent with validation therapy because it reinforces the client's belief that her mother is still alive. Reference: p. 951, Psychosocial Integrity C. The nurse should use validation therapy for the client with moderate or severe Alzheimer's disease (AD). In validation therapy, the staff member recognizes and acknowledges the client's feelings and concerns. This response is not argumentative but also does not reinforce the client's belief that her mother is still living. Reference: p. 951, Psychosocial Integrity D. Telling the client to wait until medications have been issued or that her daughter will find her mother is not consistent with validation therapy because it reinforces the client's belief that her mother is still alive. Reference: p. 951, Psychosocial Integrity

The client admitted with cerebral edema suddenly begins to have a seizure while the nurse is in the room. What will the nurse do first? A. Administer phenytoin (Dilantin) B. Draw blood C. Assess the need for additional support D. Start an intravenous (IV) line

C. Assess the need for additional support Rationale A. Phenytoin (Dilantin) is administered to prevent the recurrence of seizures, not to treat a seizure already under way. B. Drawing blood is not the priority in this situation. C. Convulsive status epilepticus must be treated promptly and aggressively. After a quick assessment by the nurse, the health care provider must be notified immediately, and intubation by an anesthesiologist, nurse anesthetist, or respiratory therapist may be necessary. D. Starting an IV is not the priority in this situation.

The nurse is providing medication instructions for a client for whom phenytoin (Dilantin) has been requested for treatment of epilepsy. The nurse plans to instruct the client to avoid which beverage? A. Apple juice B. Grape juice C. Grapefruit juice D. Milk

C. Grapefruit juice Rationale A. Apple juice does not interact with phenytoin. B. Grape juice does not interact with phenytoin. C. Grapefruit juice can interfere with the metabolism of phenytoin. D. Milk does not interact with phenytoin.

The client with dementia and Alzheimer's disease is discharged to home. The client's daughter says, "He wanders so much, I am afraid he'll slip away from me." What resource does the nurse suggest? A. Alzheimer's Wandering Association B. National Alzheimer's Group C. Safe Return Program D. Lost Family Members Tracking Association

C. Safe Return Program Rationale A. The Alzheimer's Wandering Association does not exist as an actual organization. B. The National Alzheimer's Group does not exist as an actual organization. C. The family should enroll the client in the Safe Return Program, a national, government-funded program of the Alzheimer's Association that assists in the identification and safe, timely return of those with dementia who wander off and become lost. D. The Lost Family Members Tracking Association does not exist as an actual organization.

The nurse is preparing a teaching plan for a client with migraine headaches who is receiving propranolol (Inderal) for migraine headaches. What health teaching by the nurse is important for the client? A. "Take this drug only when you have symptoms at the beginning of a migraine headache." B. "This drug is low dose, so you don't have to worry about your heart rate or blood pressure." C. "This drug will relieve the pain during the aura phase soon after a headache has started." D. "Take this drug as prescribed every day, even when feeling well, to prevent a migraine."

D. "Take this drug as prescribed every day, even when feeling well, to prevent a migraine." Rationale A. For prevention purposes, this drug should be taken daily, not intermittently. Abruptly stopping a beta-blocker may cause adverse symptoms. Reference: p. 931, Physiological Integrity B. This drug can lower blood pressure and decrease pulse rate. Reference: p. 931, Physiological Integrity C. Inderal is considered a preventive drug; efficacy as an abortive drug has not been substantiated by research. Reference: p. 931, Physiological Integrity D. Propranolol (Inderal) is a beta-blocker and is taken to prevent the development of a migraine headache. Reference: p. 931, Physiological Integrity

The client has Parkinson disease (PD). Which nursing intervention best protects the client from injury? A. Discouraging the client from activity B. Encouraging the client to watch the feet when walking C. Suggesting that the client obtain assistance in performing ADLs D. Monitoring the client's sleep patterns

D. Monitoring the client's sleep patterns Rationale A. Active and passive range-of-motion (ROM) exercises, muscle stretching, and activity are important to keep the client with PD mobile and flexible. B. The client with PD should avoid watching his or her feet when walking to prevent falls. C. The client with PD should be encouraged to participate as much as possible in self-management, including ADLs. Occupational and physical therapists can provide training in ADLs and the use of adaptive devices, as needed, to facilitate independence. D. Clients with PD tend to not sleep well at night because of drug therapy and the disease itself. Some clients nap for short periods during the day and may not be aware that they have done so. This sleep misperception could put the client at risk for injury (e.g., falling asleep while driving).

The nurse is administering the intake assessment for a newly admitted client with a history of seizures. The client suddenly begins to seize. What does the nurse do next? A. Documents the length and time of the seizure B. Forces a tongue blade in the mouth C. Restrains the client D. Positions the client on the side

D. Positions the client on the side Rationale A. Documenting the length and time of seizures is important, but not while the seizure is occurring. B. Forcing a tongue blade in the mouth can cause damage. C. Restraining the client can cause injury. D. Turning the client on the side during a generalized tonic-clonic or complex partial seizure is indicated because he or she may lose consciousness.